Hello, this will be a discussion over the uses of different tubes for the GI system. The objectives for this presentation are that at the completion of this study, the student will be able to differentiate tubes used for various gastrointestinal disorders, describe the indications for and patient assessments needed for each type of tube, and describe the nursing responsibilities when caring for a patient with the different types of tubes. One of the important considerations with any GI tube is understanding the purposes of that tube. And we need to understand that we use different tubes for different reasons. Sometimes tubes are used to decompress the stomach, which would means suctioning out contents.
Lavage the stomach, which means kind of washing it out. Diagnosing GI disorder, so sometimes a tube is put down or up the GI system in order to scope or send in some kind of contrast medium so that we can take imaging. It can be done to administer medications and or feedings. It can be done to compress a site that is bleeding or to aspirate contents for specific analysis.
As I have said multiple times, any intervention that we are doing for a patient, any equipment that's attached to them, any tube that's inserted to them, we are responsible for its management and maintenance. We need to be able... to answer these questions whenever we are caring for any kind of a patient that has any kind of a tube. So you should be able to tell what's the purpose of the tube.
If you don't understand, then you can't properly take care of that patient. What type of order should you expect for the care and the maintenance of this tube? How will you make sure that it's in the proper location? How will you make sure that it's properly secured? How do you know if it's patent and that it's usable or it's doing its job properly?
And what type and amount, if any, of drainage should you expect? Here's a continuation of some more questions you should be able to answer whenever you're caring for this type of client. How should you assess the patient and the equipment and how often?
What potential complications should you be monitoring and assessing for? What do you need to teach the patient or their family member about this intervention? And what and how frequently do you need to document about this, caring for this patient with this tube?
These are images of nasogastric feeding tubes. so nasogastric in the name tells you that this tube is going in through the patient's nose and the tip of it is ending up in the stomach these are images of dobhoff feeding tubes which is a specific brand and they are designed for food going in liquid nutrition going in to the patient This is another nasogastric feeding tube. The brand is a CorePak. You may see these when you do your clinicals at United Regional.
This is the type of tube that I frequently see them using. I want you to take note of the fact that the tube itself has markings on it so that we can know the tube placement by the markings at the end of the nare where it's inserted. That's one of the ways that we monitor its placement. This is an example of a PEG tube, which it stands for percutaneous endoscopic gastronomy tube.
This is actually surgically inserted through the patient's abdomen and the distal end of it is in the patient's stomach. So that this bypasses the throat altogether and the patient is fed directly into their abdomen, into their stomach. This would be useful for longer term use. Patients who have the nasal gastric tubes can keep them for a few days to a couple of weeks.
PEG tubes are more permanent and longer lasting and more comfortable for the patient. And they can be used for years if necessary. to continue the patient's ability to intake food. This image shows a jejunostomy tube, often called a J-tube. The difference between this one and the PEG tube that we saw on the previous slide is that this is also surgically inserted, but the design of the tube is for it to go past the stomach and into the jejunum in the small intestines.
So it starts off being inserted through the abdomen similar to a PEG tube, but the tip is advanced until it's in the jejunum and that's where it stays. So this kind of helps to bypass the stomach. If the patient has an issue with their stomach and cannot have food in their actual stomach, then this can help.
then continue to get nutrition as it bypasses the stomach as well. This is an image of feeding a patient through a gastronomy tube by gravity so that this is a tube that the fluid whatever the feeding solution is that's been ordered by the provider to be appropriate for this patient. is poured down through the tube and you'll notice that the man is holding that container above the level of his stomach because gravity works by how high or how low that is held and so you can slow down a feeding if a patient starts complaining of say cramping or starting to feel nauseous you can immediately slow down that feeding by lowering that tube.
So we just have to manage the speed of it by the level at which we hold that. This is a device called a kangaroo pump and the other picture on here is the bag and tubing that come with it and allow the feeding to go from the bag. through the tube into whatever device the patient has that they're receiving their feeding through.
The kangaroo pump allows for continuous feeding so they would have a slower rate, a continuous rate, or also they can do bolus feedings through the kangaroo pump. It's often set up with two bags. One bag will be for the feeding concentration, whatever has been ordered for this patient and then the other is for water for flush.
A lot of the formulas that patients are fed through different tubes like this will be highly concentrated and so oftentimes the provider will order periodic flushes or scheduled flushes that will help kind of keep the patient hydrated and dilute the formula. and also keep the tubing functioning properly. The bags for this feeding will have a set amount of time that it's safe for them to be hung for because we don't want it to grow any kind of bacteria that we would then be introducing into the patient. So often these whole systems, the bags, the tubing, and everything are changed every 24 hours.
Your provider will have you orders for how frequently that should be done and then we just throw away all of the stuff and start fresh to protect the patient from getting any kind of contaminated food. So when we're talking about tube feedings, whether it be through an NG tube, a PEG tube, a J tube, any of those, and whether it be on a pump or by gravity, the formula and the timing of feedings will depend upon the dietary and caloric needs of the patient, the type of tube and its placement, and how the patient's tolerating it. Feedings can be bolus, which would be considered like mealtime feedings.
So just like most of us eat two, three meals a day, the provider would order for a patient to have a larger volume at a bolus feeding, maybe three times a day. They can also have a basal or continuous like on the kangaroo pump that could be set to be giving them maybe 30 or 40 mils an hour and then that would just be around the clock. Okay, or they could have both.
They could have a small continuous basal rate and still have bolus feedings in between it at set times. So you'll just need to be mindful of your provider's orders for that and make sure that you're following the plan, but you're also monitoring for the patient's tolerance. So as the nurse, if you think there's something the patient's not tolerating well about this feeding plan, then it's up to us to bring it to the provider's attention and let them know that maybe we need to make some adjustments to this plan.
Maybe the bolus feedings are too big or not enough or the basal rate, you know, the patient's just not seeming to move the food through their system at a fast enough rate and they're just maybe feeling nauseous. Maybe they're getting a little bloated because it's not emptying out of their... stomach fast enough so we could advocate for our patients and bring that to the provider's attention.
All right, now we're switching gears to a different type and different function of tube. This is an example of a tube for suction. This is a Salem sump tube. I want you to notice that it has a larger bore.
It's a much round, bigger round diameter tube. and it has what's called a vent on it. You'll notice that blue part of the tubing, that's an air vent that helps to keep the tube functional and the extra air that might be in the patient's stomach to be able to be pulled out.
The tube itself is generally designed for gastric contents that have to be evacuated from the patient. So you guys will recall that when I talked about the AMP of the GI system. I said that the stomach makes more than a liter of secretions and acid daily. So even if you don't eat, your stomach is creating these acids and enzymes for digestion. But if you had no peristalsis, if your system's not moving forward for whatever reason, then all of those fluids start building up in the stomach.
and this tube would be used to decompress the stomach to suction out all those secretions so that the patient doesn't feel nauseous and have periods of vomiting and of course we know that anytime we are throwing up we have a risk of aspiration because we're sending stuff up the same tube that we breathe through and so if the patient's throws up and then breathes in at the same time then they could aspirate and then we're talking about having a whole other issue because now the lungs are involved and may be getting an infection this is another example of a suctioning tube and i did want to mention that these will have measurement markings on them so that once again we can check placement at the tip, I'm sorry, at the nose where it enters so that we can monitor to make sure that this tube stays in its proper place. And this is yet another suctioning tube. This is a Levin tube. They all have pretty much the same function. The one I've seen most frequently used is that first image the Salem sump tube.
I think that's the one that United Regionals still uses. All right, it's really important that you understand the limitations and uses of these different tubes. So we talked about the feeding tubes on the previous slides, and feeding tubes are for stuff going in, and that also includes putting in medications.
Okay, so if a tube is designed for things to go in, then you may have to crush the meds and you have to obviously make sure that they're formulated in a way that's okay to crush them and then they have to be mixed in some kind of fluid so that they can go down the tube safely and then we have to make sure that we flush very well otherwise the tube can become clogged with the crushed up medications okay often we can get a liquid formulation or we get one that can be crushed or sometimes i'm dealing with a hospitalized patient sometimes we can get the med switch to a different route altogether okay now let's talk about the suction tubes that are used to decompress and remove gastric contents most of the time when the patient has this kind of tube they're going to be npo we're taking stuff out not putting stuff in however As the patient gets better, sometimes the provider will allow us to use the tube to put medication in. Okay, so it would be up to us to make sure that this patient's bowel sounds are present before we would put something in because we wouldn't want the meds to just sit there in the stomach and not get absorbed. It has to be, you know, we have to know that. peristalsis is is going to move these meds forward into the small intestines for the them to be absorbed okay otherwise there's just no point because we don't absorb from our stomach so if the tube is going to be used for med administration you have to make sure that your patient has forward flow through the gi system make sure that the med is acceptable to be crushed because they're going to be crushed and put down the tube Remember that you have to turn off the suction. Otherwise, you're going to pour the medicine down and suction it right straight back out.
Then you have to let the suction stay off for 20-30 minutes to make sure that that stomach can propulse that through to the small intestines and get that medication out of the stomach. Then you have to remember to go back and turn the suction back on. Okay, really important that we do that only when it's ordered and that we don't confuse tubes that are for feeding and tubes that are for suction. Okay, really important that you understand that students often get this concept and content confused.
So please pay close attention. When you have a tube for suction, your provider will order the amount of suction. and it'll be set at low medium or intermittent i'm sorry medium or moderate and or high most of the time it's low because that's less stress on the the inside of the stomach because the suction can be damaging to the inside of the stomach those tissues it will either be continuous or intermittent which means intermittent means the suction automatically turns on for a few seconds, turns off for a few seconds, turns back on for a few seconds, turns back off.
That's intermittent. And that's helpful because intermittent means it gets a chance for that tube to float away or pull away from the inside of the stomach lining. If it's continuous and it's high, then you can often get the tube just stuck fast.
to the inside of the stomach, which means then it's not functioning other content out. So it's not able to do the job we put it down there to do. Plus, it's doing damage to the stomach and could be causing ulcerations.
So we have now created an extra problem that wasn't there to begin with and not fix the problem that we started off to try to correct. So pay attention to your orders and watch that the tube is actually functioning. When it's on intermittent suctioning and it's on and off and on and off automatically, we have a device that sets to intermittent and it's designed to do this automatically without us having to watch it or be there the whole time flipping the dial back and forth. You'll notice that the gastric contents will start coming up the tube and then the machine will take a pause and stop suctioning and then the contents might even back up. back down the tube again and then it'll kick on and they'll come forward again but they always should come forward on the next pull more than they're going back so we need to make sure that it's actually pulling the contents and it's getting removed make sure that you always check your orders before you're discontinuing for any medication administration or for any other reason So be mindful that you don't want to just go and pull this tube without making sure that it's what you're supposed to do and verify that you're okay to put meds down it and that it's okay to turn it off long enough for safe medication administration and then you're safe to use it.
These are some different pieces of equipment that we'll use when we're doing suctioning for a patient. On the far left, that's the regulator. You can see that the dial has some colors on it.
Green, yellow, orange, and red. The farther you are into that color, then the harder the suction is. Low suction would be in the green. Moderate suction is in the yellow.
Orange is starting to become very high and then red is super high. So there might be times when a provider would want maybe for a short time period some high suction, but when a patient's on a tube to suction and it's a continuous process that we're just decompressing their stomach for whatever reason, It's generally low and intermittent that we're using. And then those two dials at the bottom of that regulator will set whether it's continuous or intermittent.
And you can turn one knob to set it in the proper range. So low intermittent is anywhere in that green and with the intermittent selected on the other dial. and then the center there is the canister wherein all of the gastric contents will be collected it has a place for the tube that's coming from the patient to be connected and then also has a place for a connection of a tube from the regulator to the canister and that's what causes the suction all those connections have to be tight or else it doesn't the suction will not be adequate.
It won't function properly if we don't have a good tight seal. So the lid has to be well secured on the canister and all of the tubes have to be really well plugged in to their places on the canister. Then on the other side of the slide there are some images that show some of the tubing that can be used and some of the connections that help Join the tubing to the connector of the canister.
We'll do a skills lab. No, pardon me. We'll do a simulation where the patient has NG suction, and you'll get a chance to look at this equipment in the lab.
These are just some images of some different connectors and what's called stopcocks for different tubes that we use. the connectors can just bring together tubes from different different angles and such and then the stopcocks are used to um they're directional so depending on whichever way is quote unquote opened then that's the direction that the flow will be in either in or out so you may see different connectors or stopcocks when you go to whatever facility you end up working at and we may see some of these when we go to united regional for our clinicals so anytime you have a tube that has different connections there's opportunity for leaks in the connection so that the flow flow is going to be messed up whichever direction if we're talking about suction tubes then it won't be suctioning properly because there's a leak and that's preventing full pressure and suction. If it's a tube feeding going in and there's not a good solid connection between the pieces, then that can leak as well.
Additionally, any kind of kinks in the hose will block off the flow, whether that could be the suction of stuff that's being pulled out or fluid that's, you know, feeding that's supposed to be going in. Regardless of what the tube is supposed to be doing, leaks and kinks and clogs can impede what the function of that tube is. Sometimes if we have clogs, it'll be either maybe we're doing suctioning and the patient has a lot of thick mucus that's built up in their stomach and so it's kind of clogging up. the tube it's not really pulling because it's some thick mucus or maybe we've used the tube for met administration and now it's clogged up because we didn't flush it properly or whoever the nurse prior to us or something so oftentimes when that happens we'll need to irrigate the tube to make sure that it stays patent or to re-establish patency For irrigation, you generally speaking can irrigate with water because the GI system is not a sterile system. We can drink from the tap water.
You can put that kind of water in the tube because it's just going into the stomach. Occasionally, when a patient is very immunocompromised or we're concerned about introducing anything like bacteria-wise that we want to be careful. We might have a specific order for sterile water for an arrogant.
So just be mindful and make sure your orders allow you to use just regular tap water and then that will be okay. All right, so the next few slides we're going to talk about feeding with tubes. All right, so tubes for enteral feeding are considered short term if they go through the mouth or the nose.
We want them in place for four weeks or less. If it goes longer than that, then we need to probably, the provider will be looking into a more permanent placement like a PEG tube. So whenever a patient has an orally or nasally placed tube, we need to make sure we're monitoring that insertion site. So if it's going through their nose, then we have to monitor the nare to make sure that we're not getting breakdown or sores developing. And that can also happen if the tube is going through their mouth.
The enteral feeding can be continuous or bolus, like I said before. It can be by gravity or by a pump. Enteral means that the feeding is going into the stomach. Nasoduodenal means the tube is going in at the nose and the end of it is in the duodenum.
And then nasodeginal would be a tube that is entering through the nose and the tip ends up in the patient's duodenum. So just let the names help you understand. where the tube is going in and where the tip is. Indications for enteral feedings. This will be a patient that is on short-term therapy needs.
They expect that within a four-week period that they'll be able to return to some normal eating patterns. Or if not, then we'll need to go to a long-term use tube like a PEG tube. This patient is able to receive and process nutrition, meds, and fluids by the gastric route, which means that they have motility.
They have peristalsis. Their GI system is functioning, but for some reason, they can't do actual oral intake through the mouth, but they can still process the food through the rest of the GI tract. contraindicated if a patient has a basilar skull fracture or has had maxillofacial surgery, including through the nose, transphenoidal, any kind of facial trauma, or uncontrolled coagulation abnormalities.
So if you think about these contraindications, they are contraindicated if a patient has a fracture because that um If the tubing was to leak, imagine the tubing leaking and that feeding substance ending up going through fractured tissues, fractured bones, and the kind of problems that could cause. Same thing with the surgeries that are in the oral and the nasal surgeries, facial trauma. because obviously, you know, there's going to be tissues that are inflamed and edema and such things, so we want to avoid that.
And then uncontrolled coagulation abnormalities simply because if the tube irritates and rubs and causes a bleed, or maybe as we're putting it down, it somehow nicks the tissues, then we could have a severe bleeding issue. so we want to be really careful and not use these tubes with those kind of patients so maintaining the tube is our responsibility we are responsible for making sure it's patent so if it becomes clogged then unclogging it is part of maintaining it we must assess the placement initially placement is assessed with x-ray in most cases and then after that assessing placement means that we're looking at the insertion site and where the tubing is marked on the length and making sure that that tube hasn't migrated in or out. It might be able to migrate in or out a couple of centimeters and still be okay, but if in doubt, make sure you ask the provider if it's okay to either push it back in if it's come out some or still use it. before you actually put anything in or take anything out with that tube if you think it might have been displaced. Assessing the site, I think I just mentioned that.
Assessing residual. Residual would be whatever's left over in the stomach. So this would be in the case of a patient that's receiving bolus feedings, oftentimes we are checking residual, which means we are aspirating out.
with a large-bore syringe the contents of their stomach before we give the next bolus feeding. So we want to make sure that the contents of their stomach is actually moving out as we're, you know, feeding them. So if I pull the residual and there's just 50 mils from the last feed, which was, you know, three, four hours ago, and I gave the patient you know, a 500 mil feeding, 50 mils residual is not a big deal.
That they're emptying. Their stomach is processing and the food is moving forward. If, however, that residual I pull is 200 mils, then I'm questioning how much their motility is working, how much their peristalsis is really moving food through the system.
So sometimes residual um You have to notify the provider that there's too much residual and you should have orders that tell you how much is acceptable and how much is not. Generally speaking, when you pull residual, you put it back. So you pull it, you measure it, and then you return it to the patient's stomach. Assessing for eyes and nose.
This is a real important thing for a patient that's on feeding. with us because we want to make sure that they have a balance of their intake and output, that their fluid balance is adequate, is appropriate, that we don't have a lot more going in that's coming out or vice versa. And then assessing hydration status because a lot of these fluids tend to be hypertonic and so they don't have a lot of water in them.
And so sometimes patients will actually become dehydrated even on full liquid feedings because there's not enough water. So if we notice the patient has become dehydrated and we need to bring that to the provider's attention and we may end up having to give the patient some extra boluses of water in between or during their feeding time. All right, just this a lot some of this will be repeat but When we're using the tube we need to make sure that we're checking residual if we have an order for it that if we're giving Medications we're mindful of whether that meds should be given through a tube or not.
Is it okay to crush it? And if not, then we need a different Formulation or a different route Additionally, there's a lot of different formulas that are fed to patients depending upon their nutritional needs and their status. So we'll need to make sure that we're actually using the correct formula as the provider has ordered and then make sure that we're flushing.
If we're anything going in through a tube, we're going to make sure that we're flushing to maintain the patency of that tube. and then occasionally we have to irrigate a tube if it's for suction because it's getting clogged up all right so just a review of some of the complications that can come that we are responsible for monitoring for we already discussed that increased risk of aspiration and the increased risk for dehydration let me talk a little bit about dumping syndrome Dumping syndrome is a condition where food moves too quickly into the small bowel after it's been ingested. Sometimes it's also called rapid gastric emptying.
It often occurs when a patient has had surgery on their stomach or their esophagus, but it can also happen with these enteral kinds of feedings. Usually The symptoms are within 10 to 30 minutes of eating and they include feeling bloated or too full after eating, having nausea, vomiting, abdominal cramping, diarrhea, flushing, dizziness, lightheadedness, and tachycardia. Occasionally patients won't have symptoms early within the first 30 minutes.
They may only have symptoms an hour to three hours. After, if that be the case, some of those signs and symptoms will be sweating, flushing, dizziness and lightheadedness, weakness, and tachycardia. Sometimes the cause of this, like I said, is the highly concentrated feedings that we're giving them. And so we might want to slow down their feeding or include more fluids. for these patients.
Additionally, we're monitoring and protecting their skin and their mucous membranes wherever that tube is entering their body. We're protecting them from feeding intolerance. We're watching to make sure that the food, the feeding that they're getting, is being tolerated well by the patient. We're protecting them from bacterial contamination.
or making sure that we don't use feeding that's been hung too long, or opening cans and not using them, or protecting them from getting contaminated. And then we're also protecting the patient from diarrhea and constipation. We are talking about the GI tract, and so anything going on with the GI tract that we're... required now to give this patient the feeding in this way we might be looking at a higher risk for diarrhea or constipation for them. I know that in your basics class you guys discussed and learned about insertion of an NG tube so just a brief reminder that we measure first from the tip of the nose to the earlobe and then we go down from there to the xiphoid process and that's the measurement that we're going to insert the tube and then we can go a few centimeters up to 15 beyond that measured length just to make sure that we're actually in the stomach.
Usually that just means that the end extra end of the tube just ends up kind of curling up. in the stomach, which was not a bad thing. And we're sure that that's its location and it's not too high in the GI tract. This image just talks about making sure that the tube stays connected to the patient's nose.
Sometimes these things are bridled, which means that they actually have an attachment that goes through the nose and the throat. secures more soundly to the exterior of the patient's nose. And then we also want to make sure that we're using some kind of securement to the patient's gown because the tube being loose can get tangled in the gown or in the sheets and blankets and then get pulled on and removed accidentally. So once again, we're going to discuss a little bit about peg tubes.
and J-tubes. These are for longer term use. Because this tube is not going down the throat, we have definitely reduced the risk of aspiration with the use of these tubes. And these can be used longer term, like I said before, months or years, or sometimes once the patient is recovered from whatever their need was to have a tube in the first place. These tubes can be removed and the patient can go back to regular eating.
It will depend upon the patient. Some complications to consider with these kind of tubes would be wound infections, cellulitis or leaking. If that tube becomes displaced, now we're talking about feeding going into the abdominal cavity, not into the stomach itself. It can increase the risk of GI bleeding if the tube irritates the surrounding tissues where it's inserted there into the stomach.
They can become dislodged prematurely, and that would be because it got caught on the blankets and accidentally pulled out. Or I had actually took care of a patient that had dementia and had a permanent feeding tube. And if we weren't careful to make sure that she couldn't get access to that tube, she would... play with it with her hands and kind of twist it around to her hand and she actually pulled it out one time and ended up having to go back to the hospital to have it reinserted a new one.
We want to make sure that we're aware of the same nursing assessments and maintenance considerations for this tube as I mentioned previously. Now we'll talk about parenteral feeding. This would be feeding that's going through an IV line into the patient's veins into their bloodstream.
We have a peripheral or we have the central access type of tubing we can use. It will depend upon the provider order and there's some other considerations we'll talk about here in a minute. There are several different kinds of central venous access devices. We have percutaneous non-tunneled catheters. Peripherally inserted central catheters, that's a PICC line.
We talk about that. We see those pretty frequently in the hospital. We have a tunneled central catheter which is placed surgically and then we have implanted vascular access ports.
Those tend to be used for patients that have cancer that requires chemotherapy. Most of the time those implanted vascular access ports are used for chemo. If a patient has one and they're admitted to the hospital, we can use them sometimes for their IV fluids and or for lab draws so that the patient doesn't have to have so many sticks. But we'll have to have permission from the provider to use any of these different kinds of central methods for feeding.
This image is really helpful for understanding the tubes because where they're inserted is not anywhere near where the distal end of that tube is. So you think about a PICC line, the length of that tube internally is quite a long way. It goes from the patient's upper arm where it enters and the distal tip of that is in the superior vena cava.
at the entrance to the heart. So it's flowing into a large blood supply at that point, but you also have to consider that anywhere along that route, if the tube somehow gets outside of that vein, now we're talking about introducing fluids into the tissues that that doesn't belong. Also, if that line isn't inserted, Sterilely and maintained sterilely, we have a highway directly to the heart and into the bloodstream for an infection.
So our central venous catheter care will include having an appropriate catheter and IV site care, strict sterile technique for dressing changes, make sure you're wearing a mask, when changing the dressing and the patient as well. We're always assessing that insertion site and maintaining it, assessing for any indicators of infection and proper IV and tubing care. So some of your facilities will have very specific policies on how frequently the dressing is changed, how often the tubing is changed, so that we're not Introducing an infection directly into this patient's bloodstream.
So some of the indications to have parenteral. Oral feeding would be a patient has an inability to ingest adequate oral foods or fluids within a 7 to 10 day time frame. So they know already that it's going to be at least that long before they can take in orally.
Then sometimes patients are unwilling to eat orally or unable to eat orally. For instance, let's say you had a patient that is severely burned and they are unable to eat an appropriate amount orally. Or, on the other hand, sometimes you can have a patient that just is refusing to have oral intake.
Perhaps they have a psychiatric illness like anorexia nervosa. I took care of a woman who had to have parenteral feedings because she was schizophrenic and she was pregnant. She had decided to stop taking her antipsychotic meds because she was concerned about how it would impact her pregnancy and her child. And so she stopped taking her meds and then she became...
Paranoid and unwilling to eat. So she thought that she shouldn't eat because she didn't trust that the food was safe. And so she was admitted into the hospital at, I think she was about seven and a half months pregnant when we were taking care of her. And she was willing to let us insert a PICC line, and we gave her parenteral feedings while the... Psychiatric doctor worked on getting her back on her medication safely.
She ended up staying in the hospital with us for close to a month while we got this worked out and she got back to her correct doses on her medications. And then by the time she discharged, she was willing to eat again. And soon after that, she had her baby. I don't know what happened to her after she discharged from us, but hopefully that is all going well for her now.
Additionally, people are indicated to have this if they have a prolonged preoperative or postoperative nutritional need. This kind of feeding is not the preferred method. The preferred method would be enteral feedings.
But if the patient is not able to, then we go with this because it's safer for them to get this kind of nutrition than not at all. But if they're able to tolerate and we can get them eating. orally or through an enteral feeding tube, that would be the preferred method. All right, some additional responsibilities we have when a patient is having parenteral feedings is we need to help identify patients who are candidates for this.
Sometimes providers don't necessarily know the intake that the patient has and what might be keeping them from having adequate oral intake. So we need to watch their nutrition status. We need to watch their Oral intake, if it decreases for an extended length of time, then perhaps it's time to think about putting in a catheter for long-term use.
Or even if it's not long-term, but something enteral, parenteral, that will help them get this nutrition. If the patient has excessive weight loss, more than we would expect, muscle wasting, or decrease tissue healing. If they're not eating enough to support their body needs or they're not eating enough to support their healing needs, then we need to think about parenteral feedings.
And if a patient has persistent nausea and vomiting and no matter what, you know, the rest of their GI tract may be fine, but they just can't stop throwing up, then we have to figure out another way to feed this person. We have to watch out for hydration status. It is still a consideration even with this kind of feeding that this patient could become dehydrated because of the concentration of the feeding.
We monitor very closely their electrolyte balances. As a matter of fact, a dietitian and the pharmacy work together to see that the feeding is tailored to the patient's needs. So someone is monitoring very closely if the potassium starts going down because the patient's physical body needs more or is losing it in some way then they add more of that to their next bag of their parenteral feeding and then obviously their calorie needs have to be balanced as well.
Sometimes feeding is done through a peripheral line, so that'd be like a regular IV line, or it could be something like a midline that's a little bit longer, more stable peripheral line, but it's still a peripheral line. It's going into a smaller vein. These can only be used short term, so if they anticipate it being more than five or seven days, then they're going to be looking at more of a central line. It is used usually to supplement oral intake. So perhaps the patient doesn't quite have their full oral intake back in line.
We might supplement with peripheral feeding, but the formulas can't have more than 10% dextrose because that's very irritating on the veins. That high concentration is too harsh on the veins. However, that amount of dextrose is often insufficient for the patient's nutritional needs.
So that has to be a balance between how much dextrose do they need versus how much is safe to put through that line. Peripheral veins can be damaged by full strength parenteral nutrition because it's too hypertonic. That means it just too concentrated for the veins to handle. And so oftentimes what they'll do is give lipids simultaneously, which will help kind of buffer the vein from that hypertonic solution.
When we're talking about the use of a central line, not a peripheral, but a central line, the feedings are still highly concentrated and hypertonic, but because it's going through a large vein and being distilled into the bloodstream quickly, it becomes isotonic when it hits the bloodstream. So it's not nearly as damaging because it's being diluted into a larger volume of blood. These can be used for varying times and for different purposes, but we can't just suddenly stop feeding this patient.
this kind of feeding. It has to be decreased or weaned gradually because their body gets used to the supply of the dextrose in this formula. And so if we just suddenly stop, then they can have rebound hypoglycemia.
So sometimes if we get into a bind where the patient's feeding is about to run out, but we don't have the next bag from... the pharmacy yet, we will substitute a solution of dextrose IV short term until that next bag of feeding is available or sometimes we'll use dextrose to slowly wean them off of the feeding. Usually what happens is the feeding will just be decreased over time as the patient is increasing their oral intake but if you have to hang dextrose you'll have a specific provider order that tells you the percent, like the concentration of dextrose to give, as well as a rate in the interim until you get that next bag of their formula feed.
All right, a couple more facts about central line feeding. A complex mixture containing proteins, carbohydrates, fats, electrolytes, vitamins, minerals, and water is used. and mixed, like I said, specific to the patient.
According to, they look at their labs, they look at their body weight, they look at their different nutritional needs, and they tailor the feeding to what this patient requires. And it is changed day by day, if necessary, to address issues as they come up. And of course, the goals of this kind of feeding are to improve nutritional status. Establish a positive nitrogen balance, maintain their muscle mass, and promote weight maintenance or gain and enhance the healing process of whatever other problems this patient is facing. I would like you all to take a look at your textbook.
There's a table. It's in chapter 41, table 41-7, I think, that tells you the... Different complications that we're watching for with a patient that has this kind of feeding. These are some of our goals as we take care of patients that are receiving this kind of nutrition. We are trying to attain an optimal level of nutrition for this patient, keep them free of infection, which is at a greater risk because of our interventions, make sure they have adequate fluid volume and fluid balance.
optimal level of activity. This patient should try to be getting up and moving, if at all possible, as much as they can. If it's just to get out of the bed and sit in the chair for a little while.
We need to have a goal of teaching them their self-care and to keep this patient free from any of these complications that are possible with this kind of intervention. All right, just a few words about maintaining a fluid balance. This kind of nutrition is going to be administered with a pump, okay, usually the same IV pump that we use for giving an antibiotic or maintenance fluids.
The flow rate should not be increased or decreased rapidly. Those things are stepped up a little at a time until we get to the full rate and stepped down a little at a time until it's discontinued. If the fluid runs out, we hang a dextrose solution.
This slide says 10%, which is usually the common one, but occasionally your provider might give you a different order, so make sure you're paying attention to what the provider has said. We are monitoring for indications of fluid balance and electrolyte balance. So we're monitoring labs and we're assessing the patient for these different balances. We're maintaining a good record of their I's and O's. We want to make sure that basically as much is going in.
is this coming out? So this patient would be on measuring of their urine output and how much oral intake, if they have any oral intake, plus what's ever in this bag and then any other IV fluids that are running. All of that is counted towards their I's and O's. We know that we should have a little bit more going in. then we actually see coming out in the urine because we have that insensible loss where we lose a little fluid from our breathing or through our skin, those kind of things.
So we always should have actually a little bit more going in than out. But if that is too much of a swaying in either direction, then we're talking about a problem that the nurse needs to investigate. Find out what's going on, why we have this imbalance in the fluid and what we can what we can do about it.
We want to measure their weights daily and when we talk about doing daily weights we need to make sure that we understand that the patient should be weighed at the same time wearing the same type of clothing so if they're just wearing a hospital gown that's perfect and they should have emptied their bladder before we weigh them that way we get a very accurate amount of And then we're also probably going to be watching blood glucose levels. A lot of times patients that are on any kind of extra feedings, whether that be parenteral or enteral, we have orders to keep monitor on their blood glucose levels because we want to make sure that we don't have either hyper or hypoglycemia going on because we're doing this feeding intervention. I know that is a lot of information on several different but related interventions that we do for patients with the GI conditions.
I know that you probably still have questions about some of this material. I would encourage you to do one of several or several of several things. Rewatch the discussion here, taking notes. Sometimes the way that I say a thing doesn't necessarily click to your understanding, so maybe you should seek out other videos that explain these in a way that makes more sense to you.
You are always welcome to come see me or email me with your questions so that I can try to clarify things. I would encourage you to look in your textbook for these different types of tubes and see which diseases and disorders that they are associated with caring for. You know, it's really important for nurses to take responsibility. for the nursing care and management of all of the tubes, lines, and devices, machines, whatever that that are associated with this patient's care because if they're not working at the very least it's not correcting the problem that it's designed to be helping with and in addition to that it may actually be making another problem altogether if that's not functioning correctly. So it's real important for you guys to get a good handle on this.
Please let me know if I can do things to help you understand it better. And I'm going to be available to you guys during my regular office hours or through email. Let me know. Thank you.